Prevention Of Shaken Baby Syndrome And Abusive Head Trauma

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Prevention of Shaken Baby Syndrome and Abusive Head TraumaPAGE 1–ABUSIVE HEAD TRAUMAWelcome to the prevention of shaken baby syndrome and abusive head trauma section of themuseum.By the end of your visit here you will be able to: define the term Abusive Head Trauma; recognize signs and symptoms of possible Abusive Head Trauma; and explain your role as a mandated reporter.Abusive Head Trauma, or AHT was formerly called Shaken Baby Syndrome, or SBS. Abusive HeadTrauma is an injury to the skull or intracranial contents of an infant or young child (younger than 5years of age) due to inflicted blunt impact and/or violent shaking.It occurs because a young child’s head is large and heavy and the neck is relatively weak, so theshaking causes the brain to rattle around inside the skull causing hemorrhaging or bleeding in thebrain.The American Academy of Pediatrics estimates that about 30 children younger than one year ofage per 100,000 are injured from Abusive Head Trauma, resulting in at least 1,200 seriouslyinjured infants and at least 80 deaths per year in the United States.PAGE 2–ABUSIVE HEAD TRAUMA INFORMATIONLet’s go to this video where Margo Singer, the Program Coordinator at the Brain Injury Association ofNew York, shares more information about Abusive Head Trauma, a condition that is 100%preventable.[VIDEO]Moderator: So, how does damage occur when a child is shaken?Margo Singer: Sure. Well, that forceful whip-like motion of the shaking back and forth will cause thebrain to be injured. Um, as I described earlier with traumatic brain injury, ah, the motion will cause theblood vessels to rupture. Um, and also blood cells to swell up and to be damaged. So it’s basically theblood that pools up that puts pressure on the brain and destroys parts of the brain cells and the brain.Professional Development ProgramFoundations in Health and Safety e-LearningPage 1For Training Purposes Only

Moderator: What are the potential signs that a child may have been shaken?Margo Singer: OK. Well, initially there might actually not be any visible signs to the head per se, it maybe more bruising on the child’s, ah, arms or um, you know, as I said, shoulders or there may be someother broken bones, but it might not be visible. In fact, we often call, ah, brain injury an invisibleepidemic because you don’t necessarily see it. Ah, but what you’ll notice in a child is ah, irritability, ah,changes perhaps in their eating patterns, um, they’ll be tired, they might be almost like lifeless like adoll. Um, they might have trouble breathing. There might even be some vomiting, um, pupils might bedilated so there might be some things with the eyes that you might be able to detect.Moderator: I’m thinking that it’s those changes, you know, you’re seeing something that’s not typical.Becky Wood Hulbert: A child right. A child that is not acting like themselves may have reoccurringissues like that.Margo Singer: Right.Moderator: So if we suspect a child has been shaken, what do we need to do?Margo Singer: Well, the first thing is to get, uh, immediate medical treatment. Um, and obviously, theearlier the better. And then we would want to call the Central Registry, uh, staff to, you know, informthem. But medical treatment is, you know, 9-1-1 immediately. That could be the difference betweenlife and death.Moderator: How is Shaken Baby Syndrome diagnosed?Margo Singer: Well, it is difficult to diagnose. First of all, the parents might, ah, be bringing the childin. They might not be aware of the situation, the circumstances. Perhaps the child was hurt in a daycare setting or perhaps the parents themselves might be involved and they don’t want to disclose. So itmay be difficult for the medical personnel because they might not be getting the full story of thecircumstances. Ah, and because brain injury is more of a functional injury than a structural injury itmight not show up normally on a CT scan or MRI. But a CT scan or MRI would be helpful in looking forProfessional Development ProgramFoundations in Health and Safety e-LearningPage 2For Training Purposes Only

that blood pooling, the subdural hematoma and there’s also eye tests that can be done to take a lookand see if there is any retinal hemorrhaging taking place.Moderator: Is there any treatment for SBS?Margo Singer: Well, usually what we’re talking about at the instance is emergency treatment. I mean,that child might even need, ah, extreme, you know, respiratory, ah, care, you know, life sustainingmeasures to support. In fact, I think children under age 1, they’re most likely to need assistance in theER to be treated for this. Ah, there might be some medications to reduce the swelling, um, there mightbe some surgery as I said to relieve that blood pooling, the pressure on the brain. Um, so again with anMRI or a CT test, you know, that they would need that to make a more definitive diagnosis.Moderator: In comparison with accidental traumatic brain injury in infants, Shaken Baby injuries havea much worse prognosis. Tell us about this.Margo Singer: Right. Because first of all the baby’s brain is still developing, um, so some of thosecognitive, emotional problems that we talked about, um, you know, they’re going to be much moreserious. Um, and then when you’re talking about things, for instance, damage to the eyes, to theretina, you might see some blindness. Um, I would say the majority, uh, maybe 80% of those childrenwho survive Shaken Baby Syndrome are going to have lifelong um, medical or neurologicalimpairments. Um, you know, as we said, the most severe, worst outcome is death. But we also seeparalysis, and we also see children in a coma or might need lifelong medical care.Moderator: So what is being done to prevent, or help prevent Shaken Baby Syndrome?Margo Singer: Sure. Well, here in NYS we have regulations that talk about providing new motherswith information before they leave the hospital. Ah, we know that caregivers in New York State arerequired to take training in Shaken Baby Syndrome. We have a lot of good prevention materials. Thestate health department now has three excellent, ah, they’re like little documentaries, so they do talkwith real families about Shaken Baby Syndrome and they’re about 7 minutes so that’s a goodprevention message. These are available on you tube. Ah, one is for parents, one is for day careproviders, and one is for fathers. So there’s a lot of good prevention information out there.Moderator: Can you help us with some tips for preventing Shaken Baby?Professional Development ProgramFoundations in Health and Safety e-LearningPage 3For Training Purposes Only

Margo Singer: Sure. Sure. Well, sometimes it’s just important for the parents to know that sometimesa baby needs to cry. It’s not necessarily a bad thing. And the parent of course needs to check to makesure that the baby’s not hungry, that the baby, you know, doesn’t need a bottle or doesn’t need theirdiaper changed, that the baby’s comfortable. But sometimes you might just need to let the baby cryout. Maybe massage the baby’s back or try to make them feel comfortable. But if that doesn’t changethe situation, then it might be incumbent on the caregiver or the parent to perhaps put the baby in thecrib or playpen safely and then leave the room and be in charge of their own emotions because as yousaid at the beginning that it may be their stress or frustration, maybe something else is going on intheir life and the baby’s crying is just kind of elevating, you know, some tension and frustration there.Moderator: And for our childcare providers they always have to make sure that they’re supervisingappropriately and, you know, they’re providing that competent supervision at all times.Margo Singer: Yes. Very important.Moderator: And you now, I think too, as a child care provider we should encourage, you know, to callthe family and say we’re having a rough time you now, is there something that you know, you canhelp, you can, you know, you can get some more information about maybe why the baby’s crying.(Right) Reach out to the family.Links to the New York State Department of Health videos Margo Singer referred to are listed in theresource section of this training.Additional information about Abusive Head Trauma including Downloadable radio PSAs for parentsand caregivers can also be found on the “Preventing Abusive Head Trauma in Children” page of theCenters for Disease Control and Prevention, or CDC, Website. The link to this specific information canbe found in the resource section of this training.PAGE 3–SKIPPER’S STORYNow that you know more information about Abusive Head Trauma, let’s go to this video where wehear from Peggy Whalen and George Lithco, who lost their son, Skipper, to Abusive Head Trauma.[VIDEO]Professional Development ProgramFoundations in Health and Safety e-LearningPage 4For Training Purposes Only

Narrator: Taking care of children can be the most satisfying and stimulating job imaginable but it is attimes frustrating and exhausting as well.George: I mean people don’t leave children with care providers that look like their gonna shake thebaby or that their gonna hit the baby or their going to commit some form of physical abuse but whatthey don’t realize is that by leaving your child with someone who doesn’t realize the danger, you’re,you’re essentially not taking a step that’s really important to protecting the baby and that is thesimplest thing, shaking’s dangerous, if you have a problem give me a call.Peggy: I think that we need to change the attitude that having to call the parents is a bad sign that Ithink the parents need to change the attitude on that too but that the daycare provider shoulddefinitely feel that if things aren’t going right, if their getting edgy they should be able to call eitherthe parent or one of the emergency numbers listed and along with that the parents have to realizethat it doesn’t mean the daycare providers incompetent, that it’s probably the best sign if that personis honest enough to call you and say you need to come and take your child right now, this is you know,they need to be home.Narrator: The death of a child is an overwhelming loss for any family.Peggy: There is no such thing really as closure.GRAPHIC:THE INFORMAL DAY CARE PROVIDER PLED GUILTY TO SECOND-DEGREE MANSLAUGHTER AND ISCURRENTLY SERVING A THREE TO TEN YEAR SENTENCE IN A MAXIMUM-SECURITY WOMEN’SPRISON.SPECIAL THANKS TO PEGGY WHALEN AND GEORGE LITHCO FOR SHARING THEIR STORY WITH US.Narrator: Skipper’s story is heartbreaking. But there are steps you can take in your program to preventor minimize children’s distress, and lessen the amount of crying before it starts. The best way tominimize or prevent children’s stress is to anticipate their needs. Know their schedules and keep thempredictable. Be alert to early signs of hunger, sleepiness or irritability. Provide an environment that’sstimulating, but not too stimulating. And safe–but not restrictive. In every child’s day there will betimes to cry. When it happens, try to comfort them immediately. Research shows that babies who arecomforted quickly tend to cry less. And babies like to be up on your shoulder, close to your body whereProfessional Development ProgramFoundations in Health and Safety e-LearningPage 5For Training Purposes Only

it’s warm and can hear your breathing and your heart. All children are different and some can besoothed more quickly than others. Always remember–Abusive Head Trauma is 100 percentpreventable. Take the time to develop your plan and communicate with families.PAGE 4–PREVENTING STRESSThe leading cause of Abusive Head Trauma is that a baby won’t stop crying and the adult gets stressedout and is unable to calm the child.Be sure to have a plan in place for times like these. Remember to: stop and take a breath; relax; seek assistance if you need it; and try again.PAGE 5–CALMING STRATEGIESSome calming strategies you can use to help a crying baby include: Go for a walk in a carrier or stroller Try giving the child a pacifier or teether to chew on Engage in mirror play Blow bubbles for the child Be silly Dance with the baby or sing to music Create white noise such as running the vacuum or dishwasher Undress the baby and blow on his or her skin (not the eyes)And remember to communicate with the families to see what strategies work with the baby at home.PAGE 6–ABUSIVE HEAD TRAUMA AND OLDER CHILDRENIf you care for school-age children, you might think that Abusive Head Trauma would never applyto the children in your care. Keep in mind that Abusive Head Trauma can occur in children as oldas five (kindergarten age). A child who has survived Abusive Head Trauma may experienceaftereffects of various levels of intensity well into the school-age years and beyond, even well intoadulthood.Professional Development ProgramFoundations in Health and Safety e-LearningPage 6For Training Purposes Only

If you care for school-age children in a Day Care Center, for example, having this knowledge ishelpful if you ever end up caring for younger children, either on a short-term/temporary/floateror long-term basis.If you work with school-age children in a Day Care Center or School Age Child Care program, thefamilies you serve may also have children of various ages enrolled in child care–so being educatedyourself in Abusive Head Trauma can help you inform parents about it and in turn protect theiryounger children.PAGE 7–REPORTING CHILD ABUSEIf you notice signs of Abusive Head Trauma or other forms of child abuse or maltreatment, you shouldcall the Statewide Central Register to make a report. In fact, all child care providers have aresponsibility to report child abuse and maltreatment, so if you ever find yourself questioning a child’ssafety you should make the call.Let’s watch this video for more information.[VIDEO]Narrator: Child care programs are often the only places where young children are seen on a daily basisfor an extended period of time. Children who are being abused or maltreated may not be able todevelop to their maximum potential. They may carry emotional scars the rest of their lives anddepending on the type and severity of abuse or maltreatment, there can be long-term physical effectsas well.There are certain people, called 'mandated reporters' who are required by law to report suspectedchild abuse. Mandated reporters include child care providers and other people who come into contactwith children on a regular basis. As a mandated reporter, you may be the first person to suspect andreport child abuse or maltreatment. It’s essential that you become knowledgeable about these issues,and take action to interrupt the 'cycle of abuse' even though you may have mixed feelings about doingso.You also have an important role in educating parents about child abuse and maltreatment and helpingthem find the resources they need during difficult times.Professional Development ProgramFoundations in Health and Safety e-LearningPage 7For Training Purposes Only

Let's find out more about what it means to be a mandated reporter.Colleen: So Brian, what are the responsibilities of a mandated reporter?Brian: Well, mandated reporters, they’re individuals who have been specifically named in family orsocial services law that have contact with children. They’re specific responsibilities are if they havereason to believe that a child has been maltreated or abused to contact the state central register.Colleen: Who are these individuals that are named mandated reporters?Brian: Well, they’re law officers, hospital personnel, social service workers, day care providers, just toname a few.Colleen: Now, there’s specific language that is used, um, to describe child abuse and maltreatment.Can you share that with us?Brian: Well, the definition of maltreatment and abuse actually are when you have a child that’s at riskof, or is in imminent risk of permanent or protracted injury. Sex abuse. Physical maltreatment, if youwill, would qualify any child when that abuse or maltreatment has been perpetrated or allowed to beperpetrated by a person legally responsible. They should then contact the state central register.Colleen: And when you say person legally responsible, what does that mean?Brian: Well, the state says that any person that has regular, consistent contact with the child can beconsidered a person legally responsible. But we’re talking about people who act in a parental role,babysitters, day care providers, a neighbor who regularly watches a child. So technically, any personwho has regular, frequent contact with a child can be considered a person legally responsible.Colleen: Let’s get on to the definition of maltreatment. How do you describe it?Brian: Well, basically, maltreatment is when the emotional, physical, or mental capacity of a child is atrisk of being diminished or for lack of a better way of putting it, the minimum degree of care that NewYork State says a child must be given. If that level isn’t reached, that child would be consideredmaltreated.Professional Development ProgramFoundations in Health and Safety e-LearningPage 8For Training Purposes Only

Colleen: Brian, what does minimum degree of care mean?Brian: Minimum degree of care is just that, the minimum standard. What you and I might consider theminimum degree is what New York State says. Any child, regardless of their race, color, or creed,they’re entitled to proper medical, education, clothing, shelter, food, basic nutrition. Those are itemsthat every child is entitled to. And then when minimum degree isn’t reached, at that point a call canbe made to the register.Colleen: OK. But let’s say that a family doesn’t have the resources to provide for their child?Brian: Which unfortunately we may still register a report. At no time would we look at a person’seconomic status to determine whether or not a report would be registered. Um, our job is to get thechild, or provide help for the family. If a person isn’t able to afford proper medical or whatever thetreatment may be it’s our job to let them know what’s out there for them–the services that areavailable. After we’ve, I guess, let the parents or the persons legally responsible, make them aware ofwhat those services are at that point a follow-up isn’t, you know, if that hasn’t taken place at thattime we would register a report.Colleen: OK. So we provide the information. We tell them where they can go, what’s available.Brian: Yes.Colleen: And then if they don’t follow through?Brian: Yes. That’s not in every instance. There are some instances where even though we might knowthat a person cannot afford whatever those services are we would still register the report. Socialservices law says that a family may be unable or unwilling. So in either scenario we would probablystill register the report.Colleen: OK. And get the family help.Brian: The help that they require. Correct.Professional Development ProgramFoundations in Health and Safety e-LearningPage 9For Training Purposes Only

Colleen: How do we know, as a mandated reporter, when to make the report?Brian: Well, there are certain signs that everyone should be aware of. There are marks and bruises.Typically, if a child tells you how they sustained the injury and you’re alerted or the mandated reporteris made aware that the person legally responsible caused it or allowed it to happen. History in ahousehold is, is very important. The types of bruises. There are types of burns where you can tell if achild was immersed or whether or not it was a spill. Um, so there are, ah, quite a few red flags thatmandated reporters can be, that, you know, they should look out for.Colleen: And make a report.Brian: Absolutely.For more detailed training on being a mandated reporter, take the New York State Office ofChildren and Family Services’ e-Learning titled “Mandated Reporter Online n catalog.shtmPAGE 8–PHYSICAL INDICATORSThere are specific physical and behavioral indicators you should be looking for and documenting ifyou suspect child abuse or maltreatment.Let’s watch this video for more information.[VIDEO]Narrator: When it comes to child abuse or maltreatment, there are some specific things to look forcalled 'indicators'.Indicators are physical and behavioral signs exhibited by children and parents that may indicate thatabuse or maltreatment is taking place.Let's hear more.Colleen: So Brian can you give us a few examples of physical indicators of child abuse?Professional Development ProgramFoundations in Health and Safety e-LearningPage 10For Training Purposes Only

Brian: Well, bruising obviously is a big one. I mean, normally children who are toddlers who fall, they’llfall on elbows, you know, bony protrusions–that’s normal. Um, handprints, belt marks, generally whenchildren are hit with an object it will leave the imprint of the object with which they were hit. Switches,um, again, cuts, marks, bruises, but primarily what does, if the child is able to communicate, what didthe child say?Colleen: Right. They tell you something.Brian: They will tell you exactly.Colleen: And you see a mark.Brian: Absolutely.Colleen: Making that connection. So, Brian, how can a provider tell the difference between a typicalchildhood injury and a suspicious one?Brian: Well, again, it can be difficult, but when children fall typically they’re going to fall on those bonyportions, um, knees. And again, we’ll ask the child exactly what happened but when an injury is of theabdomen, the back, those, typically those areas that are covered, that should raise a red flag. Andagain, we look at everything–the relationship they have with the parents. What are the persons legallyresponsible saying? What’s the child saying? Is there a history of this type of behavior with thisparticular child? And a lot of instances children just fall down a lot. They get bruised. That happens.But in other instances those bruises are caused or at least allowed to be caused by the person legallyresponsible. So primarily they have to look at bony areas and then those areas that are covered. Daycare personnel would be better apt to do that. They know their children. They’re with them every day.They have the ability to inspect those areas that are normally covered. They then might becomesuspicious based on the history they have with the family, based on what the child said, and based onthe area, the shape, the size, um, of the bruise. At that point they would be mandated to call us and atleast discuss it with us.Colleen: And that’s why for child care providers their documentation is just critical. If you’re seeingsomething, document it so that Professional Development ProgramFoundations in Health and Safety e-LearningPage 11For Training Purposes Only

Brian: Absolutely.Colleen: if you identify a pattern you have that information Brian: Absolutely.Colleen: and if you have reasonable cause to suspect and you contact the state central register.Brian: Absolutely. They must document.Colleen: Well, and then behavior also plays an enormous role in the observation and identification ofabuse and maltreatment. What should we be looking for in children?Brian: Well, behavior changes, drastic changes primarily. A child who’s normally not reticent, they’revery talkative, they’re involved with their classmates and that child all of the sudden is quiet. They’ve,they’re’ ostracized, um, for whatever reason, um, that is to me would be a red flag. Doesn’t mean thatwe would necessarily register a report, but I think that mandated reporter, the person that’s in chargeof that child should inquire to find out what the problem is.Colleen: Right. And that is talking to the family. Find out what’s going on and then documenting theirobservations Brian: Absolutely.Colleen: at the child care providers.Brian: Absolutely. In some instances that behavior might continue that could be detrimental tothemselves or other children in the classroom.Colleen: What are some behavioral indicators then that a parent or guardian might exhibit? So,beyond the child.Brian: Ideally, well, I won’t say ideally, typically, we will have a caller that will describe the parent’sdemeanor when an issue is being described to the parent. Generally this might be school officials orProfessional Development ProgramFoundations in Health and Safety e-LearningPage 12For Training Purposes Only

someone that has a day to day contact with the child and the parent. We will have inconsistentexplanations as to how a child was injured. The child will indicate that they fell down and the parentmight give us a totally different explanation. Again, it’s a red flag. We won’t register in every instancebut in most we will always err on the side of the child and register the report.Colleen: Ok. I’m just thinking if with experience a mandated reporter, a child care provider’sexperience if they see an injury that just doesn’t make sense and the parent’s telling you one thing andyou’ve got other indicators going on Brian: Absolutely.Colleen: maybe not just this isolated incident Brian: Absolutely. Those are things that we question for. Um, whether or not the teacher or the personthat’s called us have they spoken to the child’s friends? Do they have any information that wouldindicate that maybe it wasn’t exactly as it was explained by the parent? You don’t have to havefirsthand knowledge. You don’t have to have witnessed it. It doesn’t have to be fact. All it has to be isbased on your suspicion, and of course your suspicion has to be reasonable, and we’ll register thereport just based on that information.Colleen: So then this suspicion, it’s more than gut feeling?Brian: It is much more than a gut feeling. Unfortunately people have been intuitive and they will knowsomethings going on, unfortunately we need to know why other than your gut. It has to be somethingwe can see, taste or smell so to speak. Divine intervention or your guessing unfortunately isn’t enoughfor us to register a report.Colleen: But that’s why there’s the guideline of the indicators Brian: Absolutely.Colleen: that can help support Brian: Absolutely.Professional Development ProgramFoundations in Health and Safety e-LearningPage 13For Training Purposes Only

Colleen: your observations.Brian: It would be definitely to the advantage of any new mandated reporter, even someone that’sbeen doing it for a while to review those indicators. You know about bruises and burns. You know, weall know that children fall down. We’ve all done it ourselves. We know what those bruises and markslook like. If it doesn’t fit that pattern, and even if you have questions or you’re not sure, call us. We’llwalk you through it. We’ll make the determination if it’s something that should be reported.Colleen: That’s great. That’s really great.Narrator: It’s important for you to be familiar with these indicators for two reasons: first you need toknow what to watch for, and second you need to know what language to use as you document yourobservations.PAGE 9–REASONABLE CAUSE TO SUSPECTBut how do you know when it’s the right time to make the call?Let’s watch this video that explains reasonable cause to suspect and what to expect if you shouldhave to make a call to the Statewide Central Register.[VIDEO]Narrator: The decision to call the Statewide Central Register to report suspected child abuse ormaltreatment is an individual professional responsibility, based on your own reasonable cause tosuspect.It's a decision you make based on your general knowledge of what is reasonable in terms of injuriesand explanations and your specific understanding of each child in your care.Let’s hear more:Colleen: Brian, what’s the meaning of reasonable cause to suspect?Professional Development ProgramFoundations in Health and Safety e-LearningPage 14For Training Purposes Only

Brian: Reasonable cause to suspect can be a little bit ambiguous, but what reasonable cause tosuspect is should, you come across a situation, you were to explain that situation to a reasonableperson that you would come to the same conclusion. It’s not fact. It’s not necessarily truth for thatmatter but it’s based on what you see and you’re able to substantiate what you see and we think of itas being reasonable.Colleen: So it’s more than a gut feeling?Brian: It’s a lot more than a gut feeling. Um, you have some information that backs up yourreasonable cause to suspect. For instance, you have a child with a handprint on their arm. It’sreasonable to suspect that someone hit that child. What we have to then determine is who hit thatchild or who allowed that child to be placed in that situation? That’s where the confusion may come.It’s not, um, unreasonable to call us, um, and explain to us why you feel the way you do. Gut feelings,unfortunately, legally, are, that’s not reasonable for us to move on a gut feeling.Colleen: Now if you see something, um, that doesn’t give you reasonable cause to suspect, but it’s achange. It’s a change in, um, the parent’s behavior, the child’s behavior just a change, what do youdo?Brian: Depends on the change. Um, some changes children go through. Everyone goes throughchanges. There are a lot of reasons for those changes. Families split for whatever reason. Parentsdivorce. Death in the family. Ah, a sibling gets hurt or injured. Um, those changes, it’s reasonable for achild to maybe their behavior change a little bit. Where we would then want to be involved is if thatchange would be what we consider over the top and its long lasting. It’s not something that you cansay is attributed, as a mandated reporter say that it’s attributed to the death of a parent or, um, aloved one. You don’t really have a reason that you can think of for that child, for their behavior tochange as drastically as it has. Those are the things that we would be interested in and those are theitems um that we would ask you to question the child about.Colleen: And so you could cal

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